treatment paradigm of facial pain: a multi-disciplinary

Treatment Paradigm of Treatment Paradigm of Facial Pain:Facial Pain:

A multiA multi--disciplinary disciplinary approachapproach

Andrew Kokkino, MDAndrew Kokkino, MDMedical DirectorMedical Director

Oregon Neurosciences InstituteOregon Neurosciences Institute

GoalsGoals

Present the common causes of facial painPresent the common causes of facial painDifferentiate the major facial pain Differentiate the major facial pain syndromessyndromesPresent results of treatment for facial pain Present results of treatment for facial pain syndromessyndromes

Causes of facial painCauses of facial painDef: pain in the facial region including Def: pain in the facial region including orofacialorofacial and and craniofacial pain. May be associated with local craniofacial pain. May be associated with local inflammatory, inflammatory, neoplasticneoplastic, or neuralgia syndromes. , or neuralgia syndromes. Conditions featuring recurrent or persistent facial pain as Conditions featuring recurrent or persistent facial pain as the primary manifestation disease are referred to as the primary manifestation disease are referred to as FACIAL PAIN SYNDROMES.FACIAL PAIN SYNDROMES.138 possible causes of facial pain138 possible causes of facial pain

Causes of facial painCauses of facial painDentalDental

Ache, abscess, oral Ache, abscess, oral disease,disease,

Ear (Ear (otalgiaotalgia): infection): infectionEyeEye

Infection, inflammation, Infection, inflammation, virus, glaucoma, FB, virus, glaucoma, FB, shinglesshingles

Cerebral vascular Cerebral vascular dzdzAneurysms of basilar, Aneurysms of basilar, posterior posterior commcomm, SCA, , SCA, cavernous sinus cavernous sinus thrombosisthrombosis

Neck conditionsNeck conditionsTMJTMJSinus diseaseSinus diseaseCancerCancer

ChordomaChordoma, , meningiomameningioma, , neuromasneuromas, , esthesioneuroblastomasesthesioneuroblastomas, , metsmets, , dermoidsdermoids

Referred painReferred painNerve compression, anginaNerve compression, angina

PsychogenicPsychogenicDepression, atypical Depression, atypical featuresfeatures

Neurologic causes of facial painNeurologic causes of facial pain

Trigeminal neuralgiaTrigeminal neuralgiaSphenopalatineSphenopalatine neuralgianeuralgiaPostPost--herpetic neuralgiaherpetic neuralgiaMigrainousMigrainous neuralgianeuralgiaGlossopharyngealGlossopharyngeal neuralgianeuralgiaAtypical facial painAtypical facial pain

Most common causes of facial painMost common causes of facial pain

•• TemporomandibularTemporomandibular joint and muscle disorder (TMJD)joint and muscle disorder (TMJD)•• Causes recurrent or chronic pain and dysfunction in the Causes recurrent or chronic pain and dysfunction in the

jaw joint and its associated muscles and supporting jaw joint and its associated muscles and supporting tissuestissues

•• Second most commonly occurring musculoskeletal Second most commonly occurring musculoskeletal condition resulting in pain and disability (after chronic low condition resulting in pain and disability (after chronic low back pain) back pain)

•• Affects approximately 5 to 12% of the population, with an Affects approximately 5 to 12% of the population, with an •• annual cost estimated at $4 billionannual cost estimated at $4 billion•• About half to twoAbout half to two--thirds of those with TMJ disorders will thirds of those with TMJ disorders will

seek treatment. Among these, approximately 15% will seek treatment. Among these, approximately 15% will develop chronic TMJDdevelop chronic TMJD

Prevalence of TMJPrevalence of TMJ

CrossCross--sectional study sectional study (mail questionnaire, (mail questionnaire, response rate 71%)response rate 71%)(n=8,888)(n=8,888)McFarlane TV2McFarlane TV220022002Patients in a general Patients in a general medical practice, Englandmedical practice, EnglandOne month period One month period prevalence of prevalence of orooro--facial facial painpain

1818--2525 20.8%20.8%

2626--3535 29.8%29.8%

3636--4545 30.0%30.0%

46+46+ 27.6%27.6%

Prevalence of TMJ symptomsPrevalence of TMJ symptomsMales/FemalesMales/Females

Pain from TMJPain from TMJ 6.7% / 12.4%6.7% / 12.4%Joint soundsJoint sounds 12.0% / 16.5%12.0% / 16.5%Difficulty opening jawDifficulty opening jaw 8.2% / 11.2%8.2% / 11.2%BruxismBruxism 15.5% / 20.2%15.5% / 20.2%Sensitive teethSensitive teeth 30.0% / 38.9%30.0% / 38.9%Burning mouthBurning mouth 4.1% / 5.3%4.1% / 5.3%Chewing difficultyChewing difficulty 27.2% / 24.8%27.2% / 24.8%

Major Classification of Trigeminal Major Classification of Trigeminal Pain Pain -- BurchielBurchiel

Idiopathic TN 1Idiopathic TN 1 Sharp, shooting, shockSharp, shooting, shock--like, episodic lasting seconds with painlike, episodic lasting seconds with pain--free intervalsfree intervals

Idiopathic TN 2Idiopathic TN 2 Aching, throbbing, or burning more than 50% of the time. ConstanAching, throbbing, or burning more than 50% of the time. Constant background t background pain.pain.

Symptomatic TNSymptomatic TN Association with multiple sclerosis (MS). Association with multiple sclerosis (MS). DemyelinationDemyelination of the nerve or of the nerve or descending tracts. Episodic or constant paindescending tracts. Episodic or constant pain

PostherpeticPostherpetic TNTN Facial herpes zoster. Normally V1. Marked by development of Facial herpes zoster. Normally V1. Marked by development of allodyniaallodyniasuperimposed on burning superimposed on burning dysesthisiasdysesthisias. . TrophicTrophic changes possible.changes possible.

TNP: Neuropathic TNP: Neuropathic painpain

Pain from unintentional injury, cancer, stroke. Unremitting thrPain from unintentional injury, cancer, stroke. Unremitting throbbing or burning obbing or burning in affected area.in affected area.

Trigeminal Trigeminal deafferentationdeafferentation painpain

Intentional injury to TN causing burning, crawling, itching, or Intentional injury to TN causing burning, crawling, itching, or tearing.tearing.

Atypical facial painAtypical facial pain Facial pain in the context of a somatoform pain disorder. OftenFacial pain in the context of a somatoform pain disorder. Often bilateral, bilateral, outside of TN distribution with multiple pain complaintsoutside of TN distribution with multiple pain complaints

Anesthesia dolorosaAnesthesia dolorosa Excruciating pain in an insensate facial regionExcruciating pain in an insensate facial region

Trigeminal NeuralgiaTrigeminal Neuralgia

EpidemiologyEpidemiology4.7 /1,000,000 men4.7 /1,000,000 men7.2 /1,000,000 women7.2 /1,000,000 womenPeak incidence fifth to seventh decadePeak incidence fifth to seventh decadeFamilial cases are rare Familial cases are rare


Clinical characteristicsClinical characteristics““Electric ShockElectric Shock””Continuous Continuous interictalinterictal pain (worse prognosis)pain (worse prognosis)Paroxysmal disorderParoxysmal disorder


Trigger zonesTrigger zonesAs small as 1As small as 1--2 mm2 mmPain starts in trigger zone and spreadsPain starts in trigger zone and spreadsPain intensity independent of trigger zone sizePain intensity independent of trigger zone size


TriggersTriggers--trivial stimulitrivial stimuliCold airCold airTalkingTalkingChewingChewingTooth brushingTooth brushingFacial movementFacial movement


Diagnosis and testingDiagnosis and testingClinical presentationClinical presentation•• Normal exam except for trigger zonesNormal exam except for trigger zones•• 15% have sensory loss that patient does not 15% have sensory loss that patient does not

recognizerecognize


Diagnosis and testingDiagnosis and testingInternational Headache Society criteriaInternational Headache Society criteria•• Paroxysmal attacks of facial pain lasting seconds Paroxysmal attacks of facial pain lasting seconds

to less than 2 minto less than 2 min•• 4 of the following 5 characteristics4 of the following 5 characteristics

Distribution along one or more divisions of 5th nerveDistribution along one or more divisions of 5th nerveSudden, intense, sharp, stabbing pain qualitySudden, intense, sharp, stabbing pain qualitySevere painSevere painEvidence of trigger zonesEvidence of trigger zonesNo symptoms between attacksNo symptoms between attacks


Diagnosis and testingDiagnosis and testingSecondary neuralgiaSecondary neuralgia•• MSMS•• Neoplasm (Neoplasm (epidermoidepidermoid, acoustic , acoustic neuromaneuroma, ,

meningiomameningioma, trigeminal , trigeminal neuromaneuroma))

MRI, MRAMRI, MRA


PathogenesisPathogenesisUnknownUnknownCentrally mediated mechanismCentrally mediated mechanismChronic focal Chronic focal demyelinationdemyelination•• Increased afferent firingIncreased afferent firing•• Impaired inhibitory mechanisms in trigeminal Impaired inhibitory mechanisms in trigeminal

brainstem complexbrainstem complex

Trigeminal Neuralgia Trigeminal Neuralgia TreatmentTreatment

MedicationsMedicationsPercutaneousPercutaneous

•• PercutaneousPercutaneous Radiofrequency Radiofrequency RhizotomyRhizotomy•• Glycerol injectionGlycerol injection•• Balloon compressionBalloon compression

SurgicalSurgical•• MVDMVD•• RhizotomyRhizotomy•• Peripheral Peripheral denervationdenervation

RadiosurgeryRadiosurgery

Trigeminal Neuralgia Trigeminal Neuralgia TreatmentTreatment--MedicalMedical

•• DilantinDilantin--19401940•• 300300--500 mg d500 mg d

•• TegretolTegretol--19621962•• 400400--800 mg/ d. Begin 200 mg/ day800 mg/ d. Begin 200 mg/ day•• AutoinductionAutoinduction of metabolismof metabolism•• Taper after pain free 4Taper after pain free 4--6 wks6 wks•• Side effectsSide effects•• 94% pain relief within 48 hrs94% pain relief within 48 hrs

•• BaclofenBaclofen--19801980•• 4040--80 mg d80 mg d•• GABA analogGABA analog•• Combination drugCombination drug•• SupressionSupression of spinal trigeminal neuronsof spinal trigeminal neurons


•• ClonazapamClonazapam--19761976•• 1.51.5--8 mg/d8 mg/d•• Drowsiness, fatigue, dizzinessDrowsiness, fatigue, dizziness

•• ValproicValproic acidacid•• AntiepilepticAntiepileptic•• 500500--1500 mg d1500 mg d

•• LamotrigineLamotrigine•• 150150--400 mg d400 mg d•• Na channel modulatorNa channel modulator•• Combination drug (Combination drug (dilantindilantin, , tegretoltegretol))•• StevensStevens--Johnson syndromeJohnson syndrome


•• NeurontinNeurontin•• 900900--2400 mg d2400 mg d•• Anecdotally effectiveAnecdotally effective•• Few side effectsFew side effects

•• OxcarbazepineOxcarbazepine•• 600600--1200 mg d 1200 mg d •• Derivative of Derivative of carbamazepinecarbamazepine


•• Primary: Primary: CarbamazepineCarbamazepine, , oxcarbazepineoxcarbazepine•• Secondary: Secondary: LamotrigineLamotrigine•• Tertiary: Tertiary: GabapentinGabapentin , , phenytoinphenytoin

Trigeminal NeuralgiaTrigeminal NeuralgiaTreatmentTreatment-- MedicalMedical

General guidelinesGeneral guidelinesDo not Do not overtreatovertreatSmallest possible pain relieving doseSmallest possible pain relieving doseTolerance to medication with timeTolerance to medication with timeAim for Aim for monotherapymonotherapy


MedicationsMedicationsSurgicalSurgical

•• MVDMVD•• RhizotomyRhizotomy•• Peripheral Peripheral denervationdenervation

PercutaneousPercutaneous•• PercutaneousPercutaneous

Radiofrequency Radiofrequency RhizotomyRhizotomy•• Glycerol injectionGlycerol injection•• Balloon compressionBalloon compression

RadiosurgeryRadiosurgery

InvasivenessMost

Least

Trigeminal NeuralgiaTrigeminal NeuralgiaInvasive treatmentInvasive treatment

Failed medical treatmentFailed medical treatment50% of patients require an invasive procedure50% of patients require an invasive procedureTaylor your choice of invasive treatment to the Taylor your choice of invasive treatment to the patientpatientStart with the pain distribution, age and previous Start with the pain distribution, age and previous proceduresproceduresTolerate patient preferences within reasonTolerate patient preferences within reasonMaintain full compliment of proceduresMaintain full compliment of procedures

PercutaneousPercutaneous ProceduresProcedures

PercutaneousPercutaneous Radiofrequency Radiofrequency RhizotomyRhizotomy(PRR)(PRR)

Partial destruction of Partial destruction of gasseriongasserion ganglion with ganglion with heatheatGreater than 90% relief with initial procedureGreater than 90% relief with initial procedure


PRR techniquePRR techniqueCannulationCannulation of foramen of foramen ovaleovale


PRR techniquePRR techniqueCannulationCannulation of the foramen of the foramen ovaleovale


PRR techniquePRR techniqueCannulationCannulation of the foramen of the foramen ovaleovaleAim for medial sideAim for medial side


PRR techniquePRR techniqueCannulationCannulation of the of the foramen foramen ovaleovaleAim for medial sideAim for medial side


PRR techniquePRR techniqueAvoidAvoid

Oral cavityOral cavityCarotid canalCarotid canalForamen Foramen lacerumlacerumCavernous carotidCavernous carotid


PRR techniquePRR techniqueCannulationCannulation


PRR techniquePRR techniqueStimulationStimulation•• Pain reproductionPain reproduction•• Curved needleCurved needle


PRR techniquePRR techniqueLesioningLesioning•• HypoalgesiaHypoalgesia rather than analgesiarather than analgesia


PRR techniquePRR techniqueLesioningLesioning

PROPOSED PARADIGM USED TO CONVERT A STIMULUS PROPOSED PARADIGM USED TO CONVERT A STIMULUS INTENSITY TO AN INITIAL LESIONINTENSITY TO AN INITIAL LESION

Stimulation Stimulation Intensity (mV)Intensity (mV)

Probe Temperature Probe Temperature ((00C)C)

Duration of Lesion Duration of Lesion (sec.)(sec.)

<0.3<0.3 6060 6060

0.30.3--0.40.4 6565 6060

0.40.4--0.80.8 7070 6060

0.80.8--1.01.0 7575 6060

>1.0>1.0 Abort and reposition electrodeAbort and reposition electrode


PRRPRRSide effectsSide effects•• Sensory lossSensory loss•• Moderate Moderate dysesthysiadysesthysia 55--25%25%•• Severe Severe dysesthysiadysesthysia 22--10%10%•• Corneal sensory loss 20%Corneal sensory loss 20%•• KeratitisKeratitis <1%<1%•• Anesthesia dolorosa 1Anesthesia dolorosa 1--5%5%•• Weak mastication 53%Weak mastication 53%

PercutaneousPercutaneous ProceduresProceduresPRRPRR

OutcomeOutcome•• TahaTaha, , TewTew and and BuncherBuncher. . ““A prospective 15A prospective 15--year follow up of year follow up of

154 consecutive patients with trigeminal neuralgia treated by 154 consecutive patients with trigeminal neuralgia treated by percutaneouspercutaneous stereotactic radiofrequency thermal stereotactic radiofrequency thermal rhizotomyrhizotomy..””J of Neurosurgery, 1995J of Neurosurgery, 1995

•• 14 yr recurrence rate 14 yr recurrence rate -- 25%25%•• Rate of recurrence inversely proportional to density of lesionRate of recurrence inversely proportional to density of lesion

Anticipated Anticipated ½½ life of procedure about 3life of procedure about 3--5 years5 years

PercutaneousPercutaneous ProceduresProceduresGlycerol Glycerol rhizotomyrhizotomy

Mild Mild denervatingdenervating agentagent90% initially effective90% initially effective28% recurrence within one year, 50% in 2 years28% recurrence within one year, 50% in 2 yearsSensory loss in 26Sensory loss in 26--71% 71% Many initial failuresMany initial failuresAnticipated Anticipated ½½ life 2life 2--3 years3 years

PercutaneousPercutaneous ProceduresProceduresBalloon CompressionBalloon Compression

8080--90% initially effective90% initially effective28% recurrence within 6 months28% recurrence within 6 monthsTechnical problemsTechnical problems

•• General anestheticGeneral anesthetic•• Large Large trochartrochar•• NonNon--selective with unknown degree of sensory lossselective with unknown degree of sensory loss•• BradycardiaBradycardia and hypotensionand hypotension

Anticipated Anticipated ½½ life 2life 2--3 years3 years


SurgicalSurgical•• MVDMVD•• RhizotomyRhizotomy•• Peripheral Peripheral denervationdenervation


MVD: MVD: MicrovascularMicrovascular DecompressionDecompressionTreatment of choice for select populationTreatment of choice for select populationFailed medical treatmentFailed medical treatmentClassical tic symptoms respond bestClassical tic symptoms respond bestGeneral anesthesia and ICU stay General anesthesia and ICU stay Morbidity of surgeryMorbidity of surgery


MVD techniqueMVD techniquePositionPosition•• Lateral obliqueLateral oblique•• Lumbar punctureLumbar puncture


MVD techniqueMVD techniqueIncisionIncision•• 2 fingers inside mastoid notch2 fingers inside mastoid notch•• Extend above superior Extend above superior nuchalnuchal lineline


MVD techniqueMVD techniqueIncisionIncision•• Posterior emissary veinPosterior emissary vein•• Identify Identify asterionasterion


MVD techniqueMVD techniqueCraniectomyCraniectomy•• Just below Just below asterionasterion•• Extend superiorly and laterally to the transverse Extend superiorly and laterally to the transverse

and sigmoid sinusesand sigmoid sinuses•• 2.5 cm in diameter2.5 cm in diameter•• Wax mastoid air cellsWax mastoid air cells


MVD techniqueMVD techniqueDural openingDural openingRetract cerebellum medially and inferiorlyRetract cerebellum medially and inferiorly


MVD techniqueMVD techniqueOpen Open arachnoidarachnoidIdentify Identify petrotentorialpetrotentorial junctionjunctionTransect Transect petrosalpetrosal veinvein


MVD techniqueMVD techniqueQuick look at 7th and 8th nervesQuick look at 7th and 8th nerves5th N entry zone5th N entry zoneDissect arteriesDissect arteriesCoagulate veins at entryCoagulate veins at entryIvalonIvalon spongesponge


MVDMVDComplicationsComplications•• Facial numbness 2%Facial numbness 2%•• Cranial nerve deficitCranial nerve deficit 3%3%•• PeriPeri--operative morbidity 10%operative morbidity 10%•• Cerebral hemorrhage or infarction 1%Cerebral hemorrhage or infarction 1%•• PeriPeri--operative mortality .06%operative mortality .06%


MVD long term resultsMVD long term resultsBarker et al. NEJM, 1996Barker et al. NEJM, 1996•• 20 yr follow up on 1185 patients20 yr follow up on 1185 patients

80% complete pain relief after procedure80% complete pain relief after procedure7.6% partial relief7.6% partial reliefAt 10 yrs 70% still had excellent results, 4 % partial reliefAt 10 yrs 70% still had excellent results, 4 % partial reliefOf patients with incomplete reliefOf patients with incomplete relief

•• 34% resumed medication34% resumed medication•• 22% ablative procedure and medication22% ablative procedure and medication

Recurrence rates 1Recurrence rates 1--6%, most within 2 yrs6%, most within 2 yrs


Surgical treatmentSurgical treatmentMVDMVDRhizotomyRhizotomy•• Last resortLast resort


Surgical treatmentSurgical treatmentMVDMVDRhizotomyRhizotomyPeripheral Peripheral denervationdenervation•• Interrupt afferentsInterrupt afferents•• Medically unfit patient Medically unfit patient •• Immediate reliefImmediate relief

Gamma Knife Gamma Knife RadiosurgeryRadiosurgery for for Trigeminal NeuralgiaTrigeminal Neuralgia


RadiosurgeryRadiosurgeryTechnique: 80 Technique: 80 GyGy to 100% to 100% isodoseisodose line to nerve root line to nerve root entry zoneentry zoneProfile: n=220. Symptoms present 96 months on Profile: n=220. Symptoms present 96 months on average. 61% previous surgery. 36% sensory average. 61% previous surgery. 36% sensory disturbance. 70 year old median agedisturbance. 70 year old median age

Kondziolka et al, 2001


RadiosurgeryRadiosurgeryResultsResultsPain relief 82% (>50% relief)Pain relief 82% (>50% relief)64.9% complete pain relief at 6 months64.9% complete pain relief at 6 months70.3% at one yr70.3% at one yr55.8% at 5 yrs55.8% at 5 yrs13% recurrent pain b/w 213% recurrent pain b/w 2--58 months58 monthsTime to response: 2 months medianTime to response: 2 months medianIncreased Increased parasthesiasparasthesias 88--10%10%DysesthesiasDysesthesias 3.5%3.5%No motor deficitsNo motor deficits

Kondziolka et al, 2002

Trigeminal NeuralgiaTrigeminal NeuralgiaRadiosurgeryRadiosurgery

AdvantagesAdvantages•• Short procedureShort procedure•• Minimally invasiveMinimally invasive•• Low complication rateLow complication rate•• Less expensive than MVD Less expensive than MVD

DisadvantagesDisadvantages•• Unpredictable latency to reliefUnpredictable latency to relief

GlossopharyngealGlossopharyngeal NeuralgiaNeuralgia

Etiology: vascular compression of 9Etiology: vascular compression of 9thth and and 1010thth cranial nervescranial nervesSymptoms: deep throat painSymptoms: deep throat painTreatmentTreatment

MedicalMedicalOperative: decompression or Operative: decompression or transectiontransection

GlossopharyngealGlossopharyngeal NeuralgiaNeuralgia

ResultsResultsMicrovascularMicrovascular decompression in the decompression in the management of management of glossopharyngealglossopharyngeal neuralgia: neuralgia: analysis of 217 cases. analysis of 217 cases. Patel et al: Patel et al: NeurosurgeryNeurosurgery 50:70550:705--11, 2002.11, 2002.

90% immediate relief90% immediate reliefSwallowing difficultySwallowing difficultyBest results in patients with typical Best results in patients with typical symptoms, throat pain onlysymptoms, throat pain only

Paradigm of treatmentParadigm of treatment

Gatekeepers: family medicine, ER, Gatekeepers: family medicine, ER, psychologists, psychiatrists, dentists, psychologists, psychiatrists, dentists, dental specialistsdental specialistsReferral services: ENT, oral surgeons, Referral services: ENT, oral surgeons, neurologists, neurosurgeonsneurologists, neurosurgeonsCrossCross--talk and communication is keytalk and communication is key

ConclusionsConclusions

Facial pain has many causesFacial pain has many causesUnderstanding of medical treatments and Understanding of medical treatments and surgical approaches are in evolutionsurgical approaches are in evolutionMorbidity of these treatments, especially Morbidity of these treatments, especially gamma knife gamma knife radiosurgeryradiosurgery, is being , is being reconsidered as it develops into a safe reconsidered as it develops into a safe and effective technique for the treatment and effective technique for the treatment of trigeminal neuralgiaof trigeminal neuralgia

treatment paradigm of facial pain: a multi-disciplinary

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